Clinical Management of Urolithiasis PDF

Clinical Management of Urolithiasis Thomas Knoll Margaret S. Pearle Editors Clinical Management of Urolithiasis Editors Thomas Knoll Margaret S. Pearle Department of Urology Department of Urology Klinikum Sindelfingen-Böblin...

Clinical Management of Urolithiasis Thomas Knoll Margaret S. Pearle Editors Clinical Management of Urolithiasis Editors Thomas Knoll Margaret S. Pearle Department of Urology Department of Urology Klinikum Sindelfingen-Böblingen University of Texas Southwestern University of Tübingen Medical Center, Dallas, Texas Sindelfingen, Baden-Württemberg USA Germany ISBN 978-3-642-28731-2 ISBN 978-3-642-28732-9 (eBook) DOI 10.1007/978-3-642-28732-9 Springer Heidelberg New York Dordrecht London Library of Congress Control Number: 2012940206 © Springer-Verlag Berlin Heidelberg 2013 This work is subject to copyright. 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I was of course curious to find out if the authors would know all the facts I know – an old guy who has been active in Urology for nearly 40 years. The list of authors is so impressive that it was no surprise to find no stone unturned and some I had not touched myself. Most of the authors are internationally well known urological authorities and serve in national and international associations and committees setting the standards in the stone business. In the chapter on Epidemiology, I enjoyed the philosophy “that stone dis- ease should be considered a systemic disorder, characterized by a chronic metabolic condition that is periodically punctuated by a symptomatic stone event.” And it was nice to see that the first author of this book in his chapter on Epidemiology shows a sound knowledge of the essential facts of stone formation and expands the view on epidemiology to the day-to-day variations of life that may cause stone formation. Likewise the reference list of the first chapter includes classics and to a large extent actual references. Kemal Sarica in his chapter seems to miss not one publication that dealt with the pediatric stone disease and demonstrates a thorough knowledge of even the old literature. Michelle Jo Semins and Brian R. Matlaga offer a deep look into a rarely met but important problem and inform on the actual development and change in therapeutic attitude toward treatment of stones and obstruction during pregnancy. Mantu Gupta and Doh Yoon Cha include personal experience as tips for a successful treatment of stones in malformations of the urinary system and urinary diversions. Those who want to know more are offered 103 references to study. I was pleased to see their profound understanding of not only stone problems but also the technical changes that were introduced in reservoir construction to avoid stone formation. Christian Türk is Mr. Guideline in national and international committees and offers a realistic view on the metabolic workup in stone patients: “The target group of patients who would be candidates for metaphylactic measures depends on the frequency of recurrence.” With a lot of interest I have read the chapter on dietary stone prevention by Kristina L. Penniston. As a Nutritionist she offers an often neglected and dif- ferent view on the stone problem. v vi Foreword Reading her statement: “In some cases, a referral to a behavioral health professional may be useful in order to address emotional and other behavioral barriers to implementing and adhering to medical management.” I remem- bered to have asked Thomas Knoll to contact our Psychiatrists and Geneticists to find out if the very low compliance of our cystinuric patients could be part of their inherited metabolic disorder. Margaret S. Pearle, the queen of American Urolithiasis, timely addresses the disputable transition from an old dogma: low calcium diet, to a new dogma: normal calcium diet, and the facets between these two. Michael Straub M.D. offers an objective view on pharmacological stone prevention including the problems of side effects and compliance. Michael E. Lipkin and Glenn M. Preminger in their chapter on imaging shock the reader: “In 2006, there were estimated 62 million CT scans per- formed in the United States (Brenner and Hall 2007). It is estimated that an additional 29,000 cancers could be related to CT scans performed in the US in 2007”. All aspects of imaging including the tricks of the trade with low dose NCCT, ultrasound, Doppler and resistive index and the most recent development of Digital Tomosynthesis are addressed. In the chapter on Acute Flan Pain from Christopher Rippel, M.D. and Jay D. Raman, M.D., I learned a new word: “Malingering is defined as the pro- duction of false or grossly exaggerated symptoms for the purpose of external gain (such as financial compensation, avoidance of work or military duty, or seeking drugs). Renal colic is ideally suited to malingering patients since it is treated with narcotics on the basis of subjective symptoms.” A wealth of ref- erences also accompanies this chapter. Christian Seitz and Harun Fajkovic from Austria in their chapter on obser- vation vs. active treatment offer a good mixture of physiology, statistics and impressive collection of data on every aspect of conservative and expulsive therapy. The editors Thomas Knoll and Margaret S. Pearle offer a condensed view on the guidelines of indications for active treatment and procedure selection. If shock wave lithotripsy in the year 2012 would be so precise and com- plete like the chapter of Jens J. Rassweiler et al. on this topic, there would be no PNL or URS any more. Jim’s (James E. Lingeman) statistics on the stone free rate after SWL or PNL vs. stone size was my constant companion during many presentations on stone treatment since its publication in 1993, and I highly esteem a lot of work he has done. But one thing is difficult to understand: the shock wave “liquefaction of renal tissue” in animal experiments. I started working with the fourth HM-3 in Germany in the early 1980s on and I was actively involved in the development of the Lithostar and the Modulith. I remember the hema- tomas with the HM3 because this was a primary experience, but the judicious use of the other machines has prevented renal “liquefaction”. Brandon K. Isariyawongse and Manoj Monga just as Stephen Y. Nakada and J. Stuart Wolf contribute to the reader’s understanding of the fastest devel- oping technique of stone therapy: URS. Three typical “how we do it” contribu- tions with all the tips and tricks the authors have accumulated through the years and the references which justify the different approaches are presented. Foreword vii Arvind P. Ganpule and Mahesh Desai offer a look on how to do PNL based on their extremely vast experience with thousands of PNLs in one of the best urological institutions I know. Cesare Marco Scoffone and Cecilia Maria Cracco turn the patient supine for PNL and hopefully none of the many disadvantages of prone or supine position that the authors mentioned will turn into complications in any sur- geon’s hands. So that this will not be necessary: “patients should be ade- quately informed that they are facing the risk of a heavy price in terms of human costs for treating a benign pathology such as urolithiasis by means of prone PNL” … “and for all these reasons supine PNL should be preferable and advisable.” The surprise comes at the end with Thomas W. Jarrett and Faisal: Surgery in a renewed form comes back with Laparoscopy and Robotic Stone Surgery. Why not? My last comment is a tribute to a man who made many important contribu- tions to our understanding of urolithiasis. Here is one of them which should be included in all books on Urolithiasis: Fig. 1. P. Alken N IO R INE E T AT OG U R A BIO EN C R O Y H ET UR TY AT R IN N L U AL O AN MY IN KIN AT ILI CI N IO S B E FU P SP R LU SP IT CS AT N OS OR M PE SO AL C IT T TI IO IC S O N R IB I EM N O H C SU UROLITH BAD LUCK URINARY STONE DISEASE Fig. 1 The big picture Reference Finlayson B et al (1990) Theoretical chemical models of urinary stones. In: Wickham JEA, Buck AC (eds) Renal tract stone. Churchill Livingstone, London Contents 1 Epidemiology of Stone Disease......................... 1 Charles D. Scales Jr. 2 Imaging............................................ 9 Michael E. Lipkin and Glenn M. Preminger 3 Acute Flank Pain..................................... 19 Christopher Rippel and Jay D. Raman 4 Observation Versus Active Treatment................... 29 Christian Seitz and Harun Fajkovic 5 Indications for Active Treatment and Procedure Selection.. 43 Thomas Knoll and Margaret S. Pearle 6 Shock Wave Lithotripsy in the Year 2012................. 51 Jens J. Rassweiler, Hans-Martin Fritsche, Geert Tailly, Jan Klein, Pilar Laguna, and Christian Chaussy 7 Shock Wave Lithotripsy: Opinion – the Ideal Machine..... 77 James E. Lingeman 8 Ureteroscopy........................................ 83 Brandon K. Isariyawongse and Manoj Monga 9 Ureteroscopy: Opinion – No Access Sheath............... 97 Stephen Y. Nakada 10 Ureteroscopy: Opinion – No Stents...................... 101 J. Stuart Wolf Jr. 11 Percutaneous Nephrolithotomy (PNL)................... 105 Arvind P. Ganpule and Mahesh R. Desai 12 Percutaneous Nephrolithotomy: Opinion – Supine Position............................. 117 Cesare Marco Scoffone and Cecilia Maria Cracco 13 Laparoscopic/Robotic Stone Surgery.................... 123 Faisal Ahmed and Thomas W. Jarrett 14 Pediatric Stones...................................... 133 Kemal Sarica and Rahim Horuz ix x Contents 15 Stone Disease in Pregnancy............................ 155 Michelle Jo Semins and Brian R. Matlaga 16 Stones in Exceptional Situations........................ 167 Mantu Gupta and Doh Yoon Cha 17 Metabolic Work-Up.................................. 187 Christian Tuerk 18 Dietary Stone Prevention.............................. 193 Kristina L. Penniston 19 Dietary Stone Prevention: Opinion – High/Low Calcium Intake...................................... 207 Margaret S. Pearle 20 Pharmacological Stone Prevention...................... 211 Michael Straub Index................................................... 223  Epidemiology of Stone Disease 1 Charles D. Scales Jr. Contents Urinary lithiasis is a common condition in many 1.1 Prevalence................................................... 1 parts of the world, with a peak prevalence of 5–10% 1.1.1 Age............................................................... 1 in Western societies (Scales et al. 2012; Stamatelou 1.1.2 Race............................................................. 2 et al. 2003; Lieske et al. 2006). While the symptom- 1.1.3 Sex............................................................... 2 atic stone event garners most attention from patients 1.2 Risk Factors................................................ 2 and physicians alike, emerging evidence suggests 1.2.1 Potentially Modifiable Risk Factors............ 3 that stone disease should be considered a systemic 1.2.2 Fixed Risk Factors....................................... 3 disorder, characterized by a chronic metabolic con- 1.2.3 Contextual Risk Factors............................... 5 dition that is periodically punctuated by a symptom- 1.3 Healthcare Utilization................................ 5 atic stone event. A thorough understanding of the 1.4 Future Research......................................... 6 epidemiology of stone disease provides important References................................................................. 6 insights into potential strategies for managing patients with urinary lithiasis. This chapter will pro- vide an overview of the prevalence of stone disease, discuss contextual factors that may influence the development of kidney stones, and delineate muta- ble and fixed risk factors for the disease. 1.1 Prevalence 1.1.1 Age Development of renal calculi tends to occur pri- marily during middle age, with a peak incidence among men aged 40–59 years (Stamatelou et al. 2003; Hiatt et al. 1982; Curhan et al. 1994). C.D. Scales Jr., M.D. Population-based data in the United States sug- Department of Urology and Department of Medicine, gests that the prevalence of stone disease is Robert Wood Johnson Foundation/VA Clinical Scholar, increasing among adults, with a percent preva- University of California, Los Angeles, CA, USA lence of 6.3 in men and 4.1 in women, as of 1994 (Stamatelou et al. 2003) rising to 10.6% among men, Robert Wood Johnson Foundation, Stanford, CA, USA and 7.1% among women in 2007 (Scales et al 2012). e-mail: [email protected] Similarly, increasing prevalence of stone disease T. Knoll, M.S. Pearle (eds.), Clinical Management of Urolithiasis, 1 DOI 10.1007/978-3-642-28732-9_1, © Springer-Verlag Berlin Heidelberg 2013 2 C.D. Scales Jr. has been observed in Japan using population- decade, stones appeared to be more common in based data (Yoshida et al. 1999; Yasui et al. females (Novak et al. 2009). Since these studies by 2008). Currently, the age-adjusted prevalence of Scales et al. (2007) and Novak et al. (2009) are stone disease in Japan is 114.3 per 100,000, with based on inpatient discharges alone, it is difficult a peak prevalence among men aged 30–69 years to know whether these patterns represent the epi- (Yasui et al. 2008). Epidemiologic studies of demiology of stone disease or variation in health- stone disease among children have also demon- care utilization along gender lines. Using strated evidence of an increasing prevalence of population-based data from the United States, kidney stones, particularly among adolescents, Stamatelou and colleagues found that in 1994, the although a child’s risk of stone disease remains prevalence of stone disease in adult men was about far lower than that of an adult (Sas 2011; Sharma 1.5 times that of adult women (Stamatelou et al. and Filler 2010). 2003). This ratio remains stable in 2007–2010 population data from the United States, although it is decreasing among younger men and women 1.1.2 Race (Scales et al 2012). A number of potential mechanisms exist for Variation in the prevalence of stone disease exists differential risk of stone disease between men and among different racial/ethnic groups. In the United women. Estrogen may decrease the risk of cal- States, the highest prevalence of stone disease cium containing stones (Heller et al. 2002; Mattix exists in non-Hispanic Caucasians, whereas the Kramer et al. 2003). Urinary metabolites in males lowest prevalence of stone disease is among non- may be more concentrated than among females Hispanic blacks (Scales et al. 2012; Stamatelou (Curhan et al. 2001). Obesity may increase the et al. 2003; Soucie et al. 1994). Hispanic and risk of stones more among females than males, Asian populations fall between Caucasians and potentially through the mechanism of hyperin- African-Americans in terms of the prevalence of sulinemia (Taylor and Curhan 2006; Taylor et al. stone disease. To date, definitive explanatory data 2005a; Rumenapf et al. 1990; Lemann et al. 1969; for the observed variation in risk of stone disease Kerstetter et al. 1991). Despite these plausible among racial/ethnic groups remains lacking. mechanisms, additional research is necessary to definitively explain the observed risk differences between adult and pediatric males and females. 1.1.3 Sex Historically, men have been at higher risk of form- 1.2 Risk Factors ing stones than women. Healthcare utilization data suggest that the incidence of symptomatic stone Understanding the risk factors for stone disease can disease may be up to three times higher among provide insight into potential targets for primary or adult men than women (Hiatt et al. 1982; Soucie secondary prevention of urinary lithiasis. Broadly et al. 1994; Pearle et al. 2005). More recently, speaking, risk factors for the individual sort into two however, analysis of inpatient discharges for stone categories: mutable and fixed (Table 1.1). Among disease in the United States suggests that differ- the mutable risk factors are systemic disorders that ences in the incidence of stone disease among increase the risk of stone formation, typically adult men and women may be narrowing, with the through the mechanism of metabolic derangements. ratio of inpatient discharges for males and females Fixed risk factors include family history and genetic decreasing from 1.7 in 1997 to 1.3 in 2002 (Scales conditions that predispose an individual toward et al. 2007). Among hospitalized pediatric stone stone formation, and are not curable in the absence formers, girls were more likely than boys to carry of effective gene therapies. Finally, it is important to a diagnosis of stone disease (Novak et al. 2009). consider contextual factors for each individual, par- Interestingly, in the first decade of life, stones were ticularly the climate to which he or she is exposed, more common in boys, whereas in the second which can increase the risk of stone disease. 1 Epidemiology of Stone Disease 3 Table 1.1 Categorization of risk factors for kidney stone suggest an important, modifiable role for sodium formation intake in the lithogenic process. Potentially Mutable Risk Factors Finally, substantial evidence exists that high Insufficient calcium intake animal protein intake may increase the risk of High sodium intake stone formation, although not all studies are High animal protein intake consistent with this conclusion. Metabolic Metabolic syndrome (overweight, obesity, diabetes investigations suggest that urinary calcium and mellitus) uric acid excretion increase with high animal Fixed Risk Factors protein intake (Iguchi et al. 1990; Pak et al. Primary hyperoxaluria Cystinuria 1978; Fellstrom et al. 1983a, b; Breslau et al. Family history of stone disease 1988). A low animal protein diet, in conjunc- Contextual Risk Factors tion with low sodium intake and moderate Geography/local climate calcium intake, has been shown to decrease Occupational exposure to high temperature stone formation in a randomized, controlled environment trial (Borghi et al. 2002). Thus, animal pro- Military deployment to hot, arid environment tein intake is another important modifiable risk factor for stone disease. 1.2.1 Potentially Modifiable 1.2.1.2 Obesity and the Metabolic Risk Factors Syndrome Obesity and diabetes have been prospectively 1.2.1.1 Diet linked to the formation of new kidney stones in Several nutrients are believed to play a role in large cohort studies of nurses and physicians modifying the risk of stone formation. Among (Taylor et al. 2005a, b) (Fig. 1.1). Physiologically, these, the best evidence exists for the role of obesity increases urinary acidity, urinary excretion calcium intake in the pathogenesis of kidney of calcium, and urinary excretion of uric acid stones. Cohort studies of nutritional intake (Ekeruo et al. 2004; Maalouf et al. 2004; Abate among nurses and physicians demonstrated, et al. 2004; Powell et al. 2000) (Fig. 1.2). Nondiabetic contrary to popular thought at the time, that a hyperinsulinemia is associated with increased high intake of calcium was associated with dietary absorption of calcium as well as increased decreased risk of stone formation (Curhan et al. urinary excretion of calcium (Rumenapf et al. 1990; 1993, 1997a, 2004). This effect is potentially Kerstetter et al. 1991). While no high level evidence mediated through binding of oxalate by calcium exists for the role of weight loss in preventing new in the intestines, preventing absorption and stone formation, overweight and obesity appear to subsequent urinary excretion; diets with low be potentially modifiable risk factors for stone dis- calcium levels are associated with increased ease. Further investigation for the role of weight absorption and urinary excretion of oxalate loss in preventing stone disease is necessary. (Bataille et al. 1983). High levels of sodium intake have also been implicated as a risk factor for kidney stone for- 1.2.2 Fixed Risk Factors mation (Muldowney et al. 1982; Ito et al. 1993; Massey and Whiting 1995). In a controlled meta- Risk for stone disease in an individual clearly has bolic study, high sodium intake resulted in a heritable or genetic component. Some meta- increased calcium excretion (Sakhaee et al. bolic conditions, such as primary hyperoxaluria, 1993). Finally, evidence from a randomized con- are the result of genetic mutations affecting trolled trial suggests that low sodium intake, as specific enzymatic pathways which are well part of a low animal protein, moderate calcium defined. However, it is clear that even for com- diet will reduce the risk of stone formation mon calcium oxalate nephrolithiasis, some (Borghi et al. 2002). Taken together, these data amount of baseline risk is heritable. For example, 4 C.D. Scales Jr. 2.5 2 Relative risk 1.5 HPFS NHS I 1 NHS II 0.5 0 30 Body mass index Fig. 1.1 Relationship between body mass index and risk of incident kidney stones in three prospective cohorts Fig. 1.2 Relationship 7 between body weight and urinary pH. NV = normal volunteers. DM = Diabetes mellitus. UASF = uric acid 6.5 stone formers (Cameron MA et al, J Am Soc Nephrology, 24-hr urine pH 2006.) 6 5.5 5 4.5 25 50 75 100 125 150 Body Weight (in kg) NV DM UASF a family history of stone disease confers approxi- 1968). Several genes have now been linked to mately 2.5 times higher risk of an individual hypercalciuria (Khan and Canales 2009). For forming stones, as compared with those without example, polymorphisms of the vitamin D recep- a family history of stone disease (Curhan et al. tor gene (VDR) may be linked to hypercalciuria 1997b). It is likely that the vast majority of heri- and stone formation (Relan et al. 2004; Rendina table risk is polygenic in nature (Resnick et al. et al. 2004; Soylemezoglu et al. 2004). A gain of 1 Epidemiology of Stone Disease 5 function mutation of the calcium-sensing recep- 1.2.3.2 Occupational Exposure Risks tor gene (CaSR) increases the risk of hypercalciu- Several studies have examined the role of occu- ria (Vezzoli et al. 2002, 2007). Ongoing research pational exposure to dehydrating conditions is examining the role of gene expression in on the risk of stone disease. In military person- oxalate, pyrophosphate, citrate, and macromole- nel deployed to high temperature regions, the cule excretion (Khan and Canales 2009). incidence of renal colic and stones increases. (Clark 1990; Cramer and Forrest 2006; Pierce and Bloom 1945). Interestingly, stone formation 1.2.3 Contextual Risk Factors in this population appears to be quite rapid and peaks by 90 days following deployment into high A number of studies have examined local environ- temperature zones (Evans and Costabile 2005). mental factors which may influence risk of stone A study of soldiers from the United Kingdom disease in specific populations. Among these fac- deployed to the Persian Gulf noted a rapid rise tors are included geography, local climate (i.e., tem- in urinary calcium excretion, with a concomitant perature and sunlight exposure), and occupational drop in the ratio of urinary calcium to magnesium exposures. The common theme of these findings is (Parry and Lister 1975). The authors speculate that exposure to hot, dehydrating conditions that increasing calcium excretion was mediated increases the baseline risk for stone formation. by sunlight exposure (Parry and Lister 1975). Workers in hot environments, such as steel 1.2.3.1 Climate mills and glass plants, also appear to have ele- Stone formation risk has been linked to climate vated risks for stone formation. Compared with through a number of epidemiologic studies. controls working in normal temperatures, steel Geographically, areas of higher stone prevalence workers exposed to high temperatures had a much tend to correlate with hot and/or dry climates. For higher incidence of stone disease (Atan et al. example, the southeastern United States has the 2005). Likewise, glass workers chronically highest prevalence of stone disease (Stamatelou exposed to high temperatures have a higher inci- et al. 2003; Soucie et al. 1994; Finlayson 1974; dence of stone disease (Borghi et al. 1993). Mandel and Mandel 1989a, b). Temperature and Metabolic analyses in these populations suggest sunlight exposure appear to be environmental that low urine volumes, hypocitraturia, and low factors that may explain the geographic variation urine pH contributed to stone formation after in stone prevalence (Soucie et al. 1996). chronic exposure to these occupational condi- Further evidence supporting the role for tions (Atan et al. 2005; Borghi et al. 1993). local climate as a risk factor for stone disease Workers in these conditions may lack access to includes patterns of seasonal variation in the water for rehydration and/or restroom facilities to incidence of urinary stones. In both the north- maintain adequate urine output (Curhan 2007). ern and southern hemispheres, the incidence of stones tends to peak during the summer months (Prince et al. 1956; Prince and Scardino 1960; Bateson 1973). 1.3 Healthcare Utilization Recently, Brikowski and colleagues (Brikowski et al. 2008) created a model predicting the poten- Patterns of healthcare utilization for stone disease tial effects of climate change on the prevalence reflect both epidemiologic changes as well as and geographic distribution of stone disease in technologic changes. Data from the Urologic the United States. They estimate that the propor- Diseases in America Project show that inpatient tion of the US population living in high-risk areas hospital stays for stone disease have decreased in for stone disease will increase to 56% by 2050, quantity and duration (length of stay) (Pearle from a current level of 40%. This would result in et al. 2005). Observed rates of outpatient visits a predicted 1.6–2.2 million additional prevalent for stone disease have simultaneously increased cases of urinary lithiasis by 2050. in both privately insured and publicly insured 6 C.D. Scales Jr. populations (Pearle et al. 2005). Procedures have Atan L, Andreoni C, Ortiz V et al (2005) High kidney migrated from an inpatient basis to an outpatient stone risk in men working in steel industry at hot tem- peratures. Urology 65(5):858–861 basis, particularly at ambulatory surgical centers. Bataille P, Charransol G, Gregoire I et al (1983) Effect of For stone fragmentation, shock wave lithotripsy calcium restriction on renal excretion of oxalate and tends to predominate in the United States, at the probability of stones in the various pathophysio- approximately 55% of procedures. Ureteroscopic logical groups with calcium stones. J Urol 130(2): 218–223 stone removal occurs in just over two-fifths of Bateson EM (1973) Renal tract calculi and climate. Med J cases, and percutaneous nephrostolithotomy is a Aust 2(3):111–113 relatively rare procedure, at less than 5% of stone Borghi L, Meschi T, Amato F, Novarini A, Romanelli A, removal cases (Scales et al. 2011). Cigala F (1993) Hot occupation and nephrolithiasis. J Urol 150(6):1757–1760 Borghi L, Schianchi T, Meschi T et al (2002) Comparison of two diets for the prevention of recurrent stones in 1.4 Future Research idiopathic hypercalciuria. N Engl J Med 346(2): 77–84 Breslau NA, Brinkley L, Hill KD, Pak CY (1988) Review of the epidemiologic data for stone disease Relationship of animal protein-rich diet to kidney suggests a number of areas for future research. stone formation and calcium metabolism. J Clin At the basic science level, a deeper understanding Endocrinol Metab 66(1):140–146 of the genetic and proteomic basis for calcium Brikowski TH, Lotan Y, Pearle MS (2008) Climate-related increase in the prevalence of urolithiasis in the United oxalate and uric acid stones is necessary. Ideally, States. Proc Natl Acad Sci USA 105(28):9841–9846 this understanding would translate into additional Clark JY (1990) Renal calculi in army aviators. Aviat therapies to reduce the risk of stone disease, Space Environ Med 61(8):744–747 either as primary or secondary prevention. In Cramer JS, Forrest K (2006) Renal lithiasis: addressing the risks of austere desert deployments. Aviat Space terms of clinical science, the increased risks for Environ Med 77(6):649–653 stone disease from obesity and diabetes are clear. Curhan GC (2007) Epidemiology of stone disease. Urol However, it remains unclear as to whether and Clin North Am 34(3):287–293 to what extent interventions for weight loss will Curhan GC, Willett WC, Rimm EB, Stampfer MJ (1993) A prospective study of dietary calcium and other nutri- reduce the risk of stone formation in overweight ents and the risk of symptomatic kidney stones. and obese individuals. Indeed, some data suggest N Engl J Med 328(12):833–838 that low carbohydrate, high animal protein diets, Curhan GC, Rimm EB, Willett WC, Stampfer MJ (1994) which promote weight loss, can actually worsen Regional variation in nephrolithiasis incidence and prevalence among United States men. J Urol 151(4): urinary parameters and potentially increase the 838–841 risk of stone formation (Reddy et al. 2002). Curhan GC, Willett WC, Speizer FE, Spiegelman D, Surgical interventions for weight loss can also Stampfer MJ (1997a) Comparison of dietary calcium increase the risks for stone disease (Matlaga et al. with supplemental calcium and other nutrients as fac- tors affecting the risk for kidney stones in women. 2009). Additional research is required to under- Ann Intern Med 126(7):497–504 stand how to achieve weight reduction without Curhan GC, Willett WC, Rimm EB, Stampfer MJ (1997b) increasing the risk of stone formation. Finally, Family history and risk of kidney stones. J Am Soc public health interventions should be explored to Nephrol 8(10):1568–1573 Curhan GC, Willett WC, Speizer FE, Stampfer MJ (2001) ameliorate the risks for stone formation conferred Twenty-four-hour urine chemistries and the risk of by occupational and environmental exposures. kidney stones among women and men. Kidney Int 59(6):2290–2298 Curhan GC, Willett WC, Knight EL, Stampfer MJ (2004) Dietary factors and the risk of incident kidney stones References in younger women: Nurses’ Health Study II. Arch Intern Med 164(8):885–891 Abate N, Chandalia M, Cabo-Chan AV Jr, Moe OW, Ekeruo WO, Tan YH, Young MD et al (2004) Metabolic Sakhaee K (2004) The metabolic syndrome and uric risk factors and the impact of medical therapy on the acid nephrolithiasis: novel features of renal manifesta- management of nephrolithiasis in obese patients. tion of insulin resistance. Kidney Int 65(2):386–392 J Urol 172(1):159–163 1 Epidemiology of Stone Disease 7 Evans K, Costabile RA (2005) Time to development of and risk of incident kidney stones. J Am Soc Nephrol symptomatic urinary calculi in a high risk environ- 14(5):1272–1277 ment. 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Preminger Contents 2.1 Introduction 2.1 Introduction................................................ 9 Imaging remains a critical component to the 2.2 Computed Tomography............................. 9 evaluation of a patient with known or suspected 2.2.1 Indications.................................................... 9 2.2.2 Radiation Exposure...................................... 11 urolithiasis. There are a number of imaging modali- 2.2.3 Recommendations........................................ 11 ties that have been used for the evaluation of uro- 2.3 Ultrasound.................................................. 12 lithiasis. Imaging for urolithiasis has evolved over 2.3.1 Indications.................................................... 12 the years. Historically, plain abdominal radiogra- 2.3.2 Recommendations........................................ 13 phy (KUB) and excretory radiography (IVP) have 2.4 Plain Radiography..................................... 14 been considered the studies of choice for the diag- 2.4.1 Kidneys, Ureters, and Bladder (KUB)......... 14 nosis and follow-up of patients with stones. These 2.4.2 Intravenous Pyelography (IVP)................... 14 modalities have been largely supplanted by non- 2.4.3 Radiation Exposure...................................... 14 2.4.4 Recommendation......................................... 15 contrast computed tomography of the abdomen and pelvis (NCCT) and ultrasound. Though NCCT and 2.5 Magnetic Resonance Imaging (MRI)....... 15 ultrasound represent improvements over traditional 2.5.1 Indications.................................................... 15 2.5.2 Recommendations........................................ 15 radiography, neither is without limitations. The ideal imaging study for the evaluation of urolithia- 2.6 New Technology......................................... 15 2.6.1 Digital Tomosynthesis................................. 15 sis would be quickly performed, have a high sen- sitivity and specificity for the detection of stones, References................................................................. 16 and expose the patient to minimal or no radiation. This chapter will review currently available imag- ing modalities for the evaluation of urolithiasis. The advantages and disadvantages of each will be dis- cussed. Recommendations on the clinical scenarios M.E. Lipkin () where each should be used will also be made. Duke Comprehensive Kidney Stone Center, Division of Urologic Surgery, Duke University, 200 Trent Drive, DUMC 3167, Durham, NC 27713 2.2 Computed Tomography e-mail: [email protected] G.M. Preminger 2.2.1 Indications Duke Comprehensive Kidney Stone Center, Division of Urologic Surgery, Duke University, 200 Trent Drive, DUMC 3167, Durham, NC 27713 Non-contrast computed tomography (NCCT) has e-mail: [email protected] been used to evaluate for urinary stones for over T. Knoll, M.S. Pearle (eds.), Clinical Management of Urolithiasis, 9 DOI 10.1007/978-3-642-28732-9_2, © Springer-Verlag Berlin Heidelberg 2013 10 M.E. Lipkin and G.M. Preminger 30 years (Segal et al. 1978; Tessler and Ghazi suggestive of recently passed ureteral stones 1979). Initially, its primary utility was in diag- were identified in 62.4% of the patients, and nosing radiolucent stones (Segal et al. 1978; 27.5% of the NCCT were considered negative Tessler et al. 1979; Federle et al. 1981). However, for any pathology. Another report looking at it was eventually demonstrated that NCCT had 1,500 NCCT for the evaluation of flank pain improved sensitivity for diagnosing ureteral with a suspected stone found 24% of the patients stones in patients with flank pain compared with had alternative CT findings without a urinary IVP (Smith et al. 1995). Currently, NCCT is con- calculus, and 7% had a negative CT (Hoppe sidered the first-line imaging study for the evalu- et al. 2006). A urinary stone was identified in ation of the patient with acute flank pain 69% of patients. An additional pathological (Westphalen et al. 2011). The reported sensitivity condition was found in 47% of the patients who for diagnosing a ureteral stone in a patient with were diagnosed with a stone. acute flank pain ranges from 95% to 98% and the Beyond diagnosing urolithiasis, NCCT is specificity ranges from 96% to 98% (Smith et al. useful in preoperative planning for the treat- 1996; Dalrymple et al. 1998; Vieweg et al. 1998). ment of stones. Stone size and location are eas- In addition to being able to identify the stone, ily evaluated with NCCT. Skin to stone distance NCCT allows for evaluation of secondary signs as determined on preoperative NCCT is an of obstruction associated with ureteral stones. In independent predictor of successful treatment one study, NCCT was able to identify hydroureter of SWL (Pareek et al. 2005; Perks et al. 2008; in 82.7%, hydronephrosis in 80%, peri-ureteric Patel et al. 2009; Wiesenthal et al. 2010). The edema in 59%, and unilateral renal enlargement greater the skin to stone distance, the lower the in 57.2% of patients with ureteral stones (Ege efficacy of SWL. A skin to stone distance greater et al. 2003). than or equal to 11 cm has been associated with There are other advantages NCCT holds worse stone-free outcomes for SWL (Patel et al. over IVP and other imaging modalities for the 2009; Wiesenthal et al. 2010). Prone NCCT can evaluation of acute flank pain. NCCT is quickly be useful for preoperative evaluation prior to performed and does not require intravenous PNL. Prone NCCT can determine the anatomic contrast. Unlike plain radiography such as KUB relations of adjacent organs and the pleura with and IVP, NCCT can detect stones of almost any upper pole calyces (Hopper and Yakes 1990; Ng composition. The exception to this are stones et al. 2005). This can be useful in risk stratifying formed by protease inhibitors, such as indinavir, patients for potential organ injury when planning which may not be visible on NCCT (Sundaram upper pole access. and Saltzman 1999). However, often in these Stone composition can be identified as well. cases, there are secondary signs of stones such Hounsfield units (HU) or CT attenuation has been as hydroureter and periureteral or perinephric most commonly used to aide in the identification inflammation which aide in the diagnosis of stone composition (Mostafavi et al. 1998). (Sundaram et al. 1999). Brushite stones and calcium oxalate stones were Another advantage of NCCT in the evalua- shown to have the highest CT attenuations, aver- tion of the patient with acute flank pain is the aging over 1,400 HU. Uric acid stones had the ability to evaluate the rest of the abdominal and lowest CT attenuation, on average 409 HU. These pelvic viscera and possibly identify other causes measurements have clinical implications when for pain. In one study evaluating 1,000 consecu- planning surgical treatment treatments. A num- tive NCCT performed for the evaluation of renal ber of reports demonstrated that the efficacy of colic, an alternative diagnosis was made in shock wave lithotripsy (SWL) is affected by stone 10.1% of the cases (Katz et al. 2000). The attenuation on NCCT (Joseph et al. 2002; Perks majority of these diagnoses were related to the et al. 2008; Shah et al. 2010; Wiesenthal et al. genitourinary system. Ureteral stones or signs 2010). In a series looking at 30 patients who 2 Imaging 11 underwent SWL, the authors found that the suc- number of reports assessing “low-dose” CT for cess rate for fragmentation (54%) was significantly the evaluation of stones and renal colic (Kim lower for stones with a CT attenuation greater et al. 2005; Kluner et al. 2006; Poletti et al. 2007; than 1,000 HU when compared with stones with Jellison et al. 2009; Jin et al. 2010; Zilberman attenuations 500–1,000 HU (86.7%) or less than et al. 2011). One report compared a standard 500 (100%) (Joseph et al. 2002). Another group NCCT at a dose of 7.3–10 mSv versus a low-dose reported a significantly higher effectiveness NCCT at 1.4–1.97 mSv for the evaluation of coefficient for SWL treating stones with attenua- acute renal colic (Kim et al. 2005). The low-dose tion less than 1,200 HU versus those with greater NCCT had equivalent sensitivities to the standard than 1,200 HU (80.4% vs. 66.2%, p = 0.03) (Shah NCCT for the diagnosis of a ureteral stone except et al. 2010). Two reports have demonstrated that in cases of stones 7.0) may indicate an colic. For example, hyperkalemia can indicate increased risk of phosphate-containing stones or 24 C. Rippel and J.D. Raman struvite stones which form in the presence of However, a subsequent study by Bird et al. showed urease-splitting organisms. Conversely, urinary that certain CT findings (specifically hydroureter, pH in the acidic range (pH < 5.5) can indicate an hydronephrosis, periureteral, and perinephric increased risk of uric acid stones. The presence stranding) were associated with the presence of of hexagonal crystals on microscopic exam is obstruction, but that CT was still unable to deter- pathognomonic for cystinuria. A 24-h urine col- mine the degree (complete vs. partial) of obstruc- lection for a stone risk profile is indicated for tion (Bird et al. 2002). Therefore, if patients are repeat stone-formers (Pak et al. 2001). discharged from the emergency room with a diag- Unfortunately, the diagnostic yield of history, nosis of an obstructing calculus, then a follow-up physical examination, and laboratory evaluation functional study may be needed in a few weeks if is insufficient to establish a diagnosis of acute the stone does not pass (Pearle 2008). renal colic (Chen et al. 1997; Ong and Jarrett Urinary extravasation on IVU or CT indicates 2007). Therefore, the clinician is usually com- mucosal disruption due to increased hydrostatic pelled to turn to imaging modalities as the next pressure. IVU findings may include contrast step in the diagnostic armamentarium. tracking from a ruptured caliceal fornix which surrounds the renal pelvis and demarcates the lat- eral border of the psoas muscle. CT may show 3.6.5 Diagnostic Imaging perinephric stranding and fluid accumulation. Although there are rare cases of an acute abdo- A complete overview of imaging for urinary men and urinoma/abscess formation in cases of stone disease in all patients as well as in the preg- urinary extravasation (Harrow 1966; Paajanen nant patient is beyond the scope of this chapter et al. 1993), forniceal rupture generally carries no and is discussed elsewhere in this text (see Chaps. adverse prognosis (Pearle 2008) and can be 2 and 11). However, we will present a brief dis- treated conservatively (Ong and Jarrett 2007). cussion of imaging of the urinary tract in the Despite the increasing use of computed tomog- acute setting. raphy, there remains a role for plain radiography Prior to the 1990s, the gold standard for evalu- in the acute setting. Certainly, its use as a screen- ation of acute flank pain for suspected nephro- ing test for nephrolithiasis in acute flank pain has lithiasis was the intravenous urogram (IVU) or been disproven due to its poor sensitivity and retrograde pyelogram in the case of contrast specificity when compared to other imaging allergy. However, several studies in the mid to methods (Mutgi et al. 1991). However, after the late 1990s demonstrated the superiority of spiral diagnosis has been confirmed by CT, plain radio- non-contrast-enhanced computed tomography graphs can serve as a valuable follow-up tool. (CT) over IVU for its better diagnostic accuracy Multiple authors (Assi et al. 2000; Jackman et al. (Smith et al. 1995; Miller et al. 1998), its lack of 2000) have shown plain radiographs to be supe- need for IV contrast (Smith et al. 1995), its abil- rior to CT scout films in terms of sensitivity, ity to assist in alternative diagnoses (such as adn- especially for stones < 3 mm and for those in the exal or pelvic mass) (Smith et al. 1995; Abramson proximal and mid-ureter. Furthermore, Zagoria et al. 2000; Katz et al. 2000; Luchs et al. 2002), and colleagues have shown that plain abdominal its faster diagnosis (Smith et al. 1995), and for its films are quite effective at detecting and follow- decreased waiting times (Rekant et al. 2001). ing stones with Hounsfield units (HU) greater It is important to remember that non-contrasted than 300 (Zagoria et al. 2001). Therefore, a strong CT is an anatomic study and does not supply case can be made for obtaining plain abdominal information about the degree of urinary obstruc- radiographs in the acute setting for patients in tion. Sfakianakis et al. demonstrated that non-con- whom an immediate intervention is not planned. trast CT had only a 56% positive predictive value Such a practice may limit the ubiquitous use of for obstruction when CT was followed by MAG3 CT imaging in patients presenting for subsequent diuretic renography (Sfakianakis et al. 2000). evaluation. 3 Acute Flank Pain 25 Inpatient management Analgesics (IV or oral) Alpha blockers Acute Consider surgical Flank Pain drainage for solitary Yes kidney Solitary kidney or uncontrolled symptoms? Outpatient management No No History Oral analgesics Stone Yes Physical exam Obstruction Alpha blockers laboratory evaluation identified? present? Non-contrast CT Yes Repeat imaging as vindicated No Any of the following present? No Fever ( T > 100°F) Solitary kidney Inpatient management UTI Prompt surgical Leukocytosis (WBC > 15k) drainage (stent vs. Consider alternative Rising serum creatinine nephrostomy tube) diagnoses: Bilateral obstruction Yes 1. Non-urologic Consider antibiotics and Signs of sepsis 2. Alternative GU urine culture diagnosis (e.g. tumor) Fig. 3.1 Proposed approach to acute flank pain Conclusions President’s Award. American Roentgen Ray Society. In the patient who presents with acute flank AJR Am J Roentgenol 175(6):1689–1695 Abu-Ghazzeh Y, Abdu-Alro’f S (2000) The role of ultra- pain suggestive of renal colic, the goal of the sound in initial evaluation of renal colic. Saudi J diagnostic workup is to efficiency and expedi- Kidney Dis Transpl 11(2):186–190 tiously establish the diagnosis (whether uro- Ammons WS (1992) Bowditch lecture. Renal afferent logic or otherwise) and execute a plan of inputs to ascending spinal pathways. Am J Physiol 262(2 Pt 2):R165–R176 treatment to prevent complications and mini- Argyropoulos A, Farmakis A et al (2004) The presence of mize morbidity. 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AJR Am J J Nephrol 11(Suppl 1):70–72 Roentgenol 176(5):1117–1122  Observation Versus Active Treatment 4 Christian Seitz and Harun Fajkovic Contents 4.1 Observation 4.1 Observation.................................................. 29 4.1.1 Indication for Observation............................. 29 4.1.1 Indication for Observation 4.2 Active Treatment.......................................... 30 4.2.1 Indication for Active Treatment..................... 30 The vast majority of stones are passed spontane- 4.2.2 Medical Expulsive Therapy (MET)............... 33 ously before consultation of stone features (size, References................................................................. 39 location, and composition); patient’s comorbidi- ties and preferences need to be taken into con- sideration when making a treatment decision. Patients suitable for observation should have a newly diagnosed ureteral stone, well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve. Stone size should be at maximum of £10 mm since stones up to 10 mm have been included in many studies investigat- ing medical expulsive therapy (MET). However, most studies did only report on a small number of 10-mm stones. One has to be aware that the probability of stone expulsion decreases with increasing stone size and increasing ureteral proximity. Patients should be regularly monitored to assess for stone position and for hydronephro- sis. A patient eligible for observation should be informed about the likelihood and duration of stone passage, additional factors predictive for stone expulsion and possible adverse events. C. Seitz, FEBU () 4.1.1.1 Spontaneous Stone Passage Department of Urology, St. John of God Rates Hospital, Academic Teaching Hospital of the Medical Hübner et al. included six studies providing University of Vienna, Vienna, Austria e-mail: [email protected] information on 2,704 patients into a retrospec- tive analysis. The incidence of spontaneous pas- H. Fajkovic Department of Urology, General Hospital St. Pölten, sage relating to both stone size and location was St. Pölten, Austria determined from these collated studies. The rate T. Knoll, M.S. Pearle (eds.), Clinical Management of Urolithiasis, 29 DOI 10.1007/978-3-642-28732-9_4, © Springer-Verlag Berlin Heidelberg 2013 30 C. Seitz and H. Fajkovic of spontaneous passage for stones smaller than stone position, stone passage history, and time to 4 mm was 38% compared to 1.2% for those stone passage. Recent RCTs investigating time larger than 6 mm, irrespective of their position to stone passage rates in distal ureteral stones in in the ureter at the time of presentation. Calculi patients receiving MET demonstrated in the con- discovered in the distal third of the ureter had a trol arm mean stone passage rates of 2.7–9.6 days spontaneous passage rate of 45%, compared with for stones 6 mm passed ered as active treatment. without intervention. Disregarding stone size, the passage rate from the proximal ureter was 18%, from the midureter 15%, and 38% from the 4.2.1 Indication for Active Treatment distal ureter. The rate of complications reached 20% when symptoms exceeded 4 weeks in dura- Considering an otherwise healthy adult, the deci- tion compared to 7% in patients with symptoms sion for active treatment is in general based on lasting less than 4 weeks (Hübner et al. 1993). stone location (ureter or kidney), kidney func- Miller and Kane prospectively followed a total tion, symptom duration, pain tolerance, and the of 75 patients with ureteral calculi for stone pas- development of infection, determining the need sage. Clinical data included patient gender and for active stone removal or decompression of the age, stone size and location, pain medication renal collecting system. Additionally, if applica- requirements, and interval to stone passage. Of ble in a recurrent stone former, the patient’s pre- the 75 patients, 13 (17%) required intervention vious experience with observational or active and 62 (83%) were followed until spontaneous stone treatment should be taken into consider- stone passage. The time to spontaneous stone ation (Hübner et al. 1993; Miller and Kane 1999). passage of stones 5 mm. Multivariate anal- passengers, and climbing or diving activities) ysis revealed that stones that were smaller, more (Zheng et al. 2002). In some countries, aviation distal, and on the right side were more likely to pilots and public transportation professionals pass spontaneously and required fewer interven- legally need to be stone-free in order to execute tions (P = 0.012) (Miller and Kane 1999). A col- their profession. laborative (EAU/AUA) meta-analysis of studies in which spontaneous ureteral stone passage was 4.2.1.1 Ureter assessed reported a median probability of stone Active treatment of an upper urinary stone is passage of 68% for stones 5 and 4 mm using radioisotope renography to monitor renal parenchymal func- 4.2.1.2 Kidney tion (Irving et al. 2000). A MAG3 radioisotope Additional indications for active treatment for renogram was taken within 48 h of admission and kidney stones include stone growth, especially in again 1 month after the patients became stone- high-risk patients for stone formation, bilateral free. The indications for intervention were ipsi- obstruction, significant hematuria, and for more lateral loss of function (³5% loss), infection, than 2 years persistent stones. Stones >15 mm pain, or any combination of these factors. should undergo active stone removal as well as The recovery of function was determined by follow- stones persistent for 2–3 years. Stone composi- up renography. In all, 18 were initially allocated tion might influence the choice of treatment to conservative treatment, the remainder required modality (Türk et al. 2011). The natural history early intervention for pain, diminished function of 7 mm passed randomized controlled trial without significant spontaneously. The upper tracts of all patients difference comparing SWL and observation in were relieved of obstruction, and all patients were asymptomatic caliceal stones 2 cm: 2. SWL or flexible URS 3. Laparoscopy several recently published case series and our own experience suggest a clear advantage of flexible URS over SWL (Breda et al. 2008; Hyams et al. 2010). Figure 5.2 shows our pro- posed treatment algorithm for lower pole stones. 1. PCNL or SWL or flexible URS 1−2 cm 2. Laparoscopy 5.4 Procedure Selection for Active Stone Removal of Ureteral Stones 1. SWL or flex. URS 1.5 2. Flexible URS cm: 3. SWL 4. Laparoscopy 1. SWL 2. Flexible URS or PNL Yes Favourable 1−1.5 factors for cm: SWL NO 1. Flexible URS or PNL 2. SWL 1. SWL or Flexible URS 10 antegrade mm 2. SWL Proximal ureteral stones 10 1. URS mm 2. SWL Distal ureteral stones 10 mm in diameter (Jain and and the correct position of the SW source can be Shah 2007; Bergsdorf et al. 2008; Neucks et al. controlled by virtual reality without the need of 2008; Bohris et al. 2012, 2010a, b, 2003; fluoroscopy (Fig. 6.7a). AST-LithoSpace uses an Rassweiler et al. 1991; Cleveland et al. 2004; acoustic tracking system (Hartung and Schwarze Leighton et al. 2008; Hartung and Schwarze 2010; 2010) adaptable to ultrasound as well as Greenstein and Matzkin 1999; Paterson et al. fluoroscopic devices (Fig. 6.7b). 2002; Pishchalnikov et al. 2006c; Gillitzer et al. 2009; McAteer et al. 2009; Davenport et al. 2006; Madbouly et al. 2005; Yilmaz et al. 2005; Pace 6.5.6 Impact of Pulse Rates et al. 2005; Chacko et al. 2006; Kato et al. 2006; Table 6.7). To detect significant differences for Low PRF prolongs treatment time significantly smaller stones is problematic because treatment and may lead to inconvenience for patients not endpoint is difficult to determine with current maintaining a stable position. Experimental data imaging techniques. Despite longer treatment